Tuesday, January 20, 2015

How Far To Take It When The Dog Isn't Sick?

Routine blood test we ran as part of Cookie's regular wellness exam showed elevated ALT. Because she looks happy and healthy and the number was nothing crazy, we decided to wait and see whether it returns to normal in a few weeks.

Last Friday we ran the blood work again.

The ALT remains unchanged. It didn't get higher, it didn't get back down to normal. Cookie remains to look happy and healthy. So now what?

Because of the prior elevation, they included a liver profile in addition to comprehensive blood work to check liver function.

Other than the ALT everything else looks normal.

  • It is possible that this is normal level for Cookie
  • It is possible that it is caused by something outside the liver, such as low grade duodenal or pancreatic inflammation (Cookie did have pancreatitis a bit over a year ago)
  • It could be portal vein hypoplasia (PHV) which means that the blood vessels in the liver are reduced in number, resulting in reduced blood flow to the liver
  • It could be primary low grade hepatitis, which is inflammation of the liver. If that was the case we'd have to figure out why.
Possible further diagnostic include:
  • Liver ultrasound with biopsy to observe vasculature (PVH) and rule out primary hepatitis
  • Treating empirically with 4 weeks metronidazole and retest
  • GI function test (cobalamin, cPLI, folate)
  • Monitoring and retesting annually (which is something we do anyway)
The vet noted that in conversation with an internal medicine specialist, many would consider this elevation to be an individual anomaly (normal for her) in light of the absence of clinical signs. PVH is possible, but not common in large breed dogs. If the owner is concerned however, non-invasive diagnostics (ultrasound only etc) could be undertaken to rule out these other conditions.

Because the liver could be affected by something such as low-grade chronic pancreatitis, testing the GI function makes sense to me to either discover the culprit or rule it out.

We also had Jasmine's vet review the results.

He feels that unless there are any signs of illness that at this level of the ALT he would not explore further other than regular re-tests. He also feels that it is possible that this level is normal for Cookie. No other values point to an unhappy liver.

A side note:

The earlier blood work also showed elevated eosinophils, a type of white blood cells. Both Cookie and JD had the same elevation. The primary suspect were parasites, even though none showed in the stool. We treated with Panacur and Cookie's eosinophils are back to normal. 

There is a possibility that this is behind the ALT elevation and didn't have time to resolve.

I have to say that I don't like it when the blood work shows an abnormality.

Though it is not all that unusual that on a full blood panel a test value might end up outside the normal range. It happened on Jasmine's blood work a number of times that one value or another was off.

But that's just it. In Jasmine's case, it was a different value every time. This one popped up twice consistently.

I think that testing the GI function makes sense to me.

Ultrasound, while non-invasive, requires shaving of the belly. In the temperatures we've been having, running around with a bare belly doesn't sound like a good plan. And putting a sweater on Cookie? The way she runs through the bush it would probably last five minutes if that long.

Putting Cookie through invasive diagnostics while she doesn't seem to be sick at all doesn't make much sense. Or does it?

What would you do?

Related articles:
Incontinence? Cookie's Mysterious Leaks
From The End Of A Lead Line To Casa Jasmine: Meet Cookie, Our New Adoptee
And So It Begins Again(?) Our First Health-Related Heart Attack With Cookie 
I Didn't Know I Could Fly: Why Cookie Wears A Harness Instead Of A Collar
C.E.T. Oral Hygiene Chews For Dogs CAN Be A Choking Hazzard 
Our First Health-Related Heart Attack With Cookie: The Knee Or The Foot? 
Creative Solutions And An Incidental Product Review
Too Young For Pot: Cookie's Snack With A Side Of Hydrogen Peroxide  
Taming Of The Wild Beast: Cookie's Transition To Civilization  
Staying On Top Of The Ears: Cookie Is Not Impressed  
Putting The Easy Back Into Walking
Cookie's Ears Are Still Not Happy 
The Threat Of The Bulge Is Always Lurking 
Today Is Cookie's Three-Months Adoptoversary  
Cookie Meets The Electric Horse Fence And Her First Chiropractic Adjustment  
Why Examine Your Dog's Vomit? 
Why Is That Leg Still Not Happy? Cookie's Leg Keeps Getting Sore 
Cookie Too Is Insured With Trupanion
Does Being Insured Mean Being Covered? Our First Claim With Trupanion
Is Cookie's Leg Finally Getting Better?
Is Cookie Going To Be Another Medical Challenge Or Are We Looking To Closely? 
The Project That Is Cookie: Pancreatitis Up Close And Personal  
Pancreatitis: Cookie’s Blood Work   
Another Belly Upset: Pancreatitis Again Or Not?  
Happy Birthday, Cookie 
Who's Training Whom? Stick And Treat 
Don't Just Stand There, Do Something? Cookie's Mysterious Bumps 
Cookie's Mysterious Bumps Update
One Vomit, No Vomit 
Happy One-Year Adoptoversary, Cookie!
Cookie's Leaks Are Back: Garden Variety Incontinence Or Not?
Cookie's Leaks Update 
Don't Panic, Don't Panic: Know What Your Job Is 
The Continuing Saga Of Cookie's Leeks: Trying Chiropractic Approach 
Cookie's Minor Eye Irritation
Regular Wellness Exam: Cookie's ALT Was Elevated 
Cookie's Plantar Paw Pad Injury 

Do you have a story to share?

Your story can help others, maybe even save a life!

What were the first signs you noticed? How did you dog get diagnosed? What treatment did/didn't work for you? What was your experience with your vet(s)? How did you cope with the challenges?

Email me, I'll be happy to hear from you!


  1. Being in a situation like that would make for a tough decision. However, I think you made the right decision if things didn't change in between check ups and cookie seems healthy and happy. That is why it is so important to be in tune with your dog's regular state of being. So you can know when they are out of it or having an off time.

    Bonobos | http://www.chadwellanimalhospital.com/

  2. How weird that you and I both posted about this on the same day.

    Delilah's ALT is high and her TBIL is right on the high end of normal. We've had the ultrasound and it showed the liver is the right size and shape. No-one ever mentioned anything to me other than Hepatitis. Do you know what the GI testing entails? I'd really consider having that done as opposed to the biopsy. To me the biopsy is so invasive, especially as you said when the dog doesn't seem to be ill.

    1. Hi Jodi,

      yeah, interesting coincidence, isn't it? At this stage the GI function test would mean testing blood for cobalamin, folate and cPLi.

      cPLi is to see whether there is low-grade pancreatitis going on.

      The other two is testing for B vitamin absorption.

      Folat is not easily absorbed in the small intestine unless it is deconjugated there. If this part isn't functioning properly, it will show deficiency.

      Low folate level means that either assimilation and absorption of nutrients is poor, or the body is challenged by the deconjugation process, indicating a disease or disorder of the small intestine.

      High folate indicates SIBO – Small Intestinal Bacterial Overgrowth.

      Cobalamin levels are a measure of digestion.

  3. We are in this same state with one of our pups - he has neurological issues. Every time we deal with his health it's always a balance of too little, too much or just right. Not sure that there is a 'perfect' answer - but it's the perfect one that we can give at the time. It's that way with humans too in many cases. Blessings to you for taking such good care of Cookie!

    1. Thank you, Mattie. Yes, one can only make the best decision they can at any given time with the information and resources available at that time.

  4. That's such a hard one. You have to balance between what's good for the dog (noninvasive) and what you want to know. That's an answer only you -- and your veterinarian -- can answer. It's also one of the reasons I have pet insurance. Because I don't want money to be the reason I make a decision like that.

    --Wags (and purrs) from Life with Dogs and Cats

    1. Yes, it's about what's best for Cookie. But ALT is one of the things one shouldn't just shrug off.

  5. My dog has this high value too! I chronicled the whole thing in a post (http://all-around-dogs.com/wp/2014/11/13/sitting-pretty-pigeon-toed/) , and the most recent update seems to be that a diet change helped the numbers come down but not Kew enough to believe diet was a problem and it still doesn't prove the numbers are harmful (even though hers are sky high). The one possibility I didn't see you mention was trauma. This first cropped up for us after Delta had injured herself (out of our view). Given the location of the injury, my vet initially thought she may have slammed her liver when she injured herself. That may still be the issue even though the levels have stayed high (see the post for why). It can take 4 weeks or more to recover from the injury, so if you tested earlier than that, it may not have had time to work out of the system.

    1. Hi Julia,

      ALT is one of the tricky values which scare me. Sky high? What does the vet think about it?

      I didn't mention trauma because Cookie didn't have any since summer as far as I can tell. Trauma could certainly do it but it should go back down some time after, though.

      We had good 4 weeks (or a bit longer) between the two tests.

      I'll go check out your article.

  6. You will make the right decision , your heart will lead the way <3

  7. I have a 3lb chihuahua who LOVES to have abnormal blood test results. I tend to do further testing as long as it's non-invasive since she is otherwise non-symptomatic. I would rather not do surgical procedures or other more aggressive treatments/testing unless she is displaying some behavioral or health concerns.

    1. Kama, that is good strategy. Jasmine used to have one or two values off on each blood work. The difference was that it was different ones each time. Something being consistently off is more worrisome. Particularly ALT.